Sunday, August 03, 2008

Our Medicare Entitlement Crisis

The appropriate course of action should be a radically new approach to the Medicare entitlement program. We do not have a choice. The political suicide of such an action is however glaring. Our Congress is bogged down in billions of dollars of free cash flow coming from the coffers of big business looking to keep their gravy train flowing. It will take enormous servitude by our government officials to declare an end to the automatic money train known as Medicare. A restructuring of the program towards a transparent means based qualification system is necessary. Having Uncle Sam pay for an elective cataract surgery so grandma can go on an African safari is inexcusable in a time of financial collapse. The war in Iraq is peanuts compared to the financial destruction extolled by our entitlement programs.

4 comments:

Who would make the decisions as to whats the appropriate amount of care for each service?

I'm sure the cataract implanters and mfg will fight as hard for their turf as hard as the HRS will fight along with the ICD industry for their turf.

Who would say to you that the negative predictive value of MTWA test is a good enough argument to potentially eliminate 1/3 of the uneccessary ICDs going in at an expense of 20 to 30 thousand each. Yes, you could argue all of the points, but what if the 98% NPV sticks out to others as a glaring way to trim over 750 million each year in savings?

I agree with both you and the HH, something has to be done, but as long as each service continues to protect their turf screaming "cut them, not us", not much will get done.

There is a large contingent of senior citizens that are abusing Medicare. My 80 year old Dad is one of them. He hasn't met a diagnostic test he didn't like, and hypchondriac that he is, they almost all come back "negative."

p.s. to the previous poster:

Please take your spam elsewhere...this is one of the few unpolluted blogs available on the net.

Society and patients themselves would make the choice if free market forces were permitted to flourish. Our problem is government intervention and bloated bureaucracy currently commands about 30% of every healthcare dollar (and growing). In a free market approach, if granny can pay (or acquire her OWN insurance that is willing to pay for such items) then she can get whatever she wants. Asking government, with its highly funded and influential special-interest groups to determine benefits, is frought with all kinds of conflicts, as you point out.

Regarding MTWA and ICD's, the stake was drilled in the heart of that debate at the American Heart Assoc meeting 2007 when the MASTER II trial results were presented. Recall that the aim of the MASTER study was to determine whether an abnormal T-wave alternans test result is associated with subsequent life-threatening ventricular tachyarrhythmias in patients for whom an ICD was indicated on MADIT II criteria. The results? The mean age of patients was 65 years, mean ejection fraction at baseline was 24% and most patients had a prior history of heart failure. Indeterminate tests were reported in 107 patients, of whom 69 were retested with a definitive result obtained in 59%. Baseline MTWA test was negative in 214 patients and “non-negative” in 361 patients. A primary endpoint event occurred in 22 MTWA negative patients (10%) and 48 “non-negative” patients (13%), with no difference between the groups (HR 1.26 CI 0.76–2.09, p=0.37). Subgroup analysis suggested that patients with a QRS interval <120 ms were at low risk regardless of MTWA status. Total mortality was lower in patients with a negative MTWA test (6% vs. 13%, p=0.02) So although total mortality was lower in MTWA negative patients (BTW, no one knows why), MTWA failed to differentiate its primary endpoint, predicting life-threatening tachyarrhythmias. So much for the "98% negative predictive value" you quote. Further, the study was not even a prospective randomized trial, but rather a prospective cohort study, so the implications for patients who might not receive an ICD on the basis of a negative test remains unproven.

It will be evidence-based approaches to evaluating actual outcomes of therapies (like the MASTER trial) that will ultimately determine what patients (and their insurers) will pay for, not sound bites from companies. To me, that's the way it should be. Unfortunately, many of our "therapies" have not nor will not be studied, so in those instances, we'll still have to turn to "expert" consensus statements to determine for which procedures third parties will pay.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.